Geriatric Experience Questions
12 month Follow-up Expert Answers
Mom failed the driving test but insists that she should be allowed to drive. How do I stop her from driving?
The restriction of driving privileges signifies a loss of independence and mobility for the person with Alzheimer’s disease. The desire for independence may prevent the patient from giving up the car keys willingly. The patient’s judgment and insight may be impaired such that she cannot comprehend the reasoning behind the decision to revoke driving privileges because she only remembers that she has always driven safely. Be firm, yet supportive, during the non-driving transition as the patient may feel angry and depressed. You may be able to help relieve your patient’s family by taking responsibility, as a physician, for telling your patient she cannot drive and writing a “do not drive” order. This may help take the onus off the family and allow them to move toward implementing supportive interventions. Common strategies used by families to prevent or limit driving include offering to drive the person or arranging for other transportation. As a last resort, the family may need to remove the vehicle from the premises, such as parking the car on another block or in a neighbor’s driveway, hiding the car keys or disabling the car.
Mom wandered out of her apartment last night and the police brought her back. How do I prevent her from wandering away?
Wandering can be aimless or purposeful roaming that causes a person with Alzheimer’s to become lost or intrude in inappropriate places. It can happen anytime, at any place and can be life-threatening for the person, so it must be considered a priority safety concern. This patient may have wandered for a number of reasons. A person with Alzheimer's disease can experience confusion at certain times of the day or night and he or she may lose the ability to recognize familiar people, places and objects. She may experience fear arising from the misinterpretation of sight and sounds, or she may feel a desire to fulfill former obligations, such as going to work or looking after a child. She may also be searching for a familiar object or person.
To reduce wandering behavior, the family can try some of the following strategies: Encourage controlled movement and exercise to reduce anxiety, agitation and restlessness. Try to involve the person in daily activities, such as folding laundry or preparing dinner. Remind the person that he or she is in the right place and offer reassurance if he or she feels lost, abandoned or disoriented. If the person is searching for a lost object, offer to help find whatever the person may be searching for. To keep the person with Alzheimer’s safe, the family can inform the neighbors of the patient’s condition and provide them with the family’s telephone numbers for emergency contact. Since the person may wander on foot or by car, bus or other mode of transportation, the family must ensure that the patient has identification, preferably in the form of a medical bracelet.
In this patient’s case, if the daughter is unable to assure her mother’s safety because she lives alone, you must raise the discussion of 24-hour supervision via in-home care or alternate living arrangements.
How can I make Mom change her clothes? She wears the same clothes for days and refuses to change.
The task of selecting appropriate clothing and putting it on in the correct order can be challenging for people with Alzheimer’s. Often, the behavior of refusing to change clothes can result from the patient’s inability to process information, make choices and carry out tasks. Advise the family to simplify choices by offering the patient two options of clothing (e.g. blue dress or white dress) and keeping the closet free of excess clothing. Sometimes a patient may prefer a particular outfit that is comfortable and familiar to her and she refuses to wear anything else. In this situation, some families have purchased duplicate outfits so that the soiled outfit can be exchanged for a clean one without causing anxiety to the patient. The caregiver can organize the process of dressing by laying out clothing in the order it is put on, or handing the patient one each piece while giving short, simple instructions. If the patient continues to resist the caregiver’s attempts to help dress her, then professional in-home care providers may be required.
The Aricept doesn’t seem to be helping. Can you give Mom/Dad some other medication that will stop the disease?
There are no known treatments that will slow or stop the progression of the underlying dementia.
Her current medication, Aricept and the related medications, Exelon and Reminyl, each provide only symptomatic improvement in cognitive symptoms of dementia. Most patients have a modest and temporary improvement. If you feel Aricept is no longer helping then it is time to attempt stopping Aricept to see if there are any changes in mom’s functional ability or quality of life.
A slow decline in the patient’s cognition and function is expected, even if Aricept is still working. If after stopping the Aricept, you do notice a worsening of the patient’s functional ability or quality of life, you can restart the medicine and continue on with symptomatic treatment.
If Aricept is no longer effective, you could try one of the other closely related agents, Exelon or Reminyl or move onto a medication in another class of cognitive enhancers, e.g., Namenda. Namenda provides only symptomatic improvement in cognition and does NOT modify the underlying disease. Yet some patients (about 1 in 6) do have a measurable response even in advanced dementia. Eventually though the patient will lose any response to Namenda as the disease progresses.
Mom’s/Dad’s medications are expensive; would it be safe to stop any of her/his current drugs?
The following are common medications prescribed to geriatric patients with cost-benefit and risk-benefit ratios that may not be favorable. These medications could be stopped one at a time and the results evaluated. Patients need to be evaluated individual as risk and treatment goals differ with each patient. The prescription prices costs quoted here are from Drugstore.com as of June 14, 2011. This list is ordered by most cost savings to least.
· Aricept 5 mg qd –
Cost 30 tablets $ 280 (brand); generic donepezil 30 tablets $ 180
Since it provides only symptomatic relief; if the family no longer feels it works this is a prime candidate for cost reduction.
· Spiriva 18 mcg inhaled daily cost for 30 days $ 230
Advair 500/50 one puff BID cost for 30 days $$286
Combivent MDI (combination of albuterol and ipratropium ) 2-4 puffs QID 30 day supply cost $190 (2 puffs daily) to $ 380 (4 puffs daily)
Albuterol MDI prn cost for 30 days $ 125
This combination of inhalers is VERY costly and does not follow the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. The patient could start over with an inhaled anticholinergic, such as tiotropium; then add a long-acting Beta-2 agonist, such a salmeterol; and provide a PRN albuterol inhaler.
· Plavix 75 mg po qhs cost for 30 tablets $ 196
The indication for Plavix combined with ASA is weak. The CHADS2 score is only 1, if hypertension is controlled. You could stop Plavix and continue with daily ASA.
· Elavil 25 mg one po qhs - $ 4 cost for 30 tablets
Seroquel 25 mg one po qhs –$ 100 cost for 30 tablets
Likely being used as sedatives. Seroquel is a VERY costly sedative and too risky to use as a sedative.
Elavil is being used for anticholinergic sedative effects and may worsen cognition, cause constipation and other ADEs. Better to use trazodone if a daily sedative is needed.
· Atorvastatin 20 mg daily; Cost for 30 days $ 149
She/he may not need this at all. You need to check the LDL and the benefit of use may occur years in the future so life expectancy also needs to be considered.
Atorvastatin is currently only available as brand Lipitor a generic statin such a simvastatin 40mg – 30 tablets are $ 28 while pravastatin 40 mg tablets are about $26 for 30 tablets . There would be the additional cost of checking LDLs to titrate to the new dose needed to keep LDL under 100 mg/dL.
· Prilosec 20 mg po qd cost for 30 capsules $ 47
Should continue PPI daily for 50% reduction in risk of GI bleeds but use generic omeprazole 20 mg. usually about 1/3 that cost. NOTE: OTC Prilosec is not much cheaper and may be a greater out of pocket cost if the patient has prescription insurance of any type ( plans usually do not pay for OTCs)
· Gingko Biloba prn and Glucosamine/Chondrotin prn
Benefit of these supplements is questionable so almost any cost is excessive . Furthermore, Gingko has antiplatelet properties that increase risk of a GI bleed, and has not been found by the NIH to improve cognition. Ask if Glucosamine/Chondrotin helps with pain – if so continue to use – if not discontinue. There is some concern about glucosamine making control of diabetes difficult but the supporting data is not strong.